1063832822 NPI number — BROOKSIDE RADIOLOGY CONSULTANTS, INC.

Table of content: (NPI 1063832822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063832822 NPI number — BROOKSIDE RADIOLOGY CONSULTANTS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSIDE RADIOLOGY CONSULTANTS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063832822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 BROOKSIDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOURNE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02532-8315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-743-5691
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 BROOKSIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOURNE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02532-8315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-743-5691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
CHIEF RADIOLOGIST
Authorized Official Telephone Number:
508-743-5691

Provider Taxonomy Codes

  • Taxonomy code: 111NR0200X , with the licence number:  CH2416 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y45291 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com